Radiotherapy Without Borders

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“You cannot hope to build a better world without improving the individuals. To that end each of us must work for his own improvement, and at the same time share a general responsibility for all humanity, our particular duty being to aid those to whom we think we can be most useful.”

– Marie Curie


We at ProKnow have been hard at work for almost three years building the next-generation cloud platform for radiation therapy data archive and communication, anatomy contouring, peer review, and big data analytics. This platform will not only help modern radiation therapy clinics pursue common goals (data storage, remote access, workflow efficiency, standardization, automation, etc.), but it will open up new worlds in terms of big data discovery and outcomes studies.

It is called ProKnow DS, and to say we are excited would be an understatement.

Now, it just so happens there is another immediate and high-impact side benefit of ProKnow DS: It is an ideal conduit to facilitate practical education and the sharing of best practices between global sites. For example, ProKnow DS is an ideal way to connect experts from around the world with clinicians in developing countries. There are many regions where clinicians are gaining access to the most modern of delivery devices but haven’t caught up in building the resources and skills to do critical planning tasks.

As such, ProKnow has launched an initiative called Radiotherapy Without Borders. To learn more about this initiative, we spoke with ProKnow co-founder, Benjamin Nelms.

Tell us about the genesis of Radiotherapy Without Borders. How did it get started?

“Well, it was something that just came together at the right time — a confluence of events, so to speak. For one, we’ve of course been developing this really useful, super-cool, cloud-based platform for radiation oncology, all along knowing it would have huge potential to connect institutions. But, as can happen, we got into a grind to finish version 1.0 and, for a time at least, we had to table some of our big, bold dreams.

So there we are chugging away at ProKnow DS, the finish line so close we can almost taste it, and then – boom! at the perfect time – I have a conversation with Dr. Ken Olivier from The Mayo Clinic. Ken is a radiation oncologist and Vice Chair for Education at Mayo, and he had just returned from giving a talk in Tanzania.1 He filled me in on his talk and Mayo’s goals for international outreach and training, and it all just snapped into place …”

What snapped into place?

“What we could do to help, that’s what snapped into place! I’ll try to explain.

There is a site in Tanzania called Ocean Road Cancer Institute. At Ocean Road, they are gaining more and more access to modern radiation therapy technologies, things like high-speed CT for 3D planning, linear accelerators capable of IMRT and VMAT and IGRT and the like – things we have come to know as standard here in the United States. However, despite getting the tech, they are in the very early stages of developing the human resource talent to do the basic tasks associated with it, tasks such as reading the images, contouring targets and critical anatomy, designing treatment plans, assessing dose distributions and plan quality, that kind of thing. Well of course, to develop and train that human talent doesn’t happen overnight, and hiring or borrowing that talent from places like North America or Europe or Australia or other places would be unrealistically expensive.x

But – and here we see the opportunity come more into view – consider the fact that radiotherapy is largely digital, or let’s say software-driven, in nature. Many tasks are done at the computer. Well, with that the case, can’t we then “virtualize” a good portion of the education?”

You mean offer online lectures and training courses?

“Well that, sure. But in radiation therapy, skills are developed by seeing examples, doing the tasks yourselves, assessing your work, practicing to improve your performance, then repeating for other examples. Over and over. Lectures are important, sure, but when you’re talking about a task, practice makes perfect.”

And that’s where ProKnow comes in?

“And that’s where ProKnow comes in. Not only our cloud-based anatomy contouring and treatment-planning quality system modules, but also ProKnow DS, our interactive, cloud-based RT-PACS.”

Break the process down for us. Walk us through it.

“Great idea. Let’s do that. I’ll break it into three parts, though. Each is important in its own way. In fact, these three parts really define our general framework for Radiotherapy Without Borders, but for the sake of example, I’ll use Ocean Road Cancer Institute in Tanzania paired with The Mayo Clinic here in the USA.

Part one: Let’s talk anatomy. Accurately identifying and outlining key anatomy is crucial to radiotherapy planning. To help build those skills, we (ProKnow that is) will give all radiation oncologists and residents at Ocean Road Cancer Institute full access to our online contouring accuracy program. Without needing anything more than high-speed internet and a web browser, these clinicians in Tanzania can start practicing the identification and outlining of critical anatomy on CT and MR image sets. After each attempt, they can compare their work to the experts and then watch video walkthroughs where those experts describe their methods in detail. After that, they can practice contouring each organ as often as they want.”

Online contouring practice and assessment, provided essentially as a “technology grant” to Ocean Road. Now, that contouring program is an existing ProKnow service, so where does The Mayo Clinic come into play?

“Great question! I’ll get there in a minute, for sure, but first let me describe part two.

Part two is the same as part one, conceptually, but instead of identifying and outlining anatomy, the clinicians from Tanzania will be able to practice creating high-quality treatment plans over a library of standard body sites, each with well-defined dose prescriptions, organ-at-risk constraints, and our web-based plan scoring system. For each case study in the library, the patient images and anatomy are provided, and the user, or trainee, must design the treatment plan using their treatment planning-system and based on their delivery technology. It allows them to practice, then measure their performance, then learn. It’s a logical, separate quality system to complement the contouring program I described earlier.

Well, as you know, we already have the technology for the treatment-planning practical skills assessments, just as we do for the anatomy contouring, and we have growing libraries of case studies for both. But earlier you asked, “Where does The Mayo Clinic come in,” and that’s where this all comes together beautifully with part three.

Part three is when we connect Ocean Road virtually to The Mayo Clinic via ProKnow DS. This is when the magic really starts to happen.”

Okay. You seem excited about this, so let’s hear about this magic.

“You couldn’t stop me from telling you even if you tried. Here it goes.

ProKnow DS is a cloud-based RT-PACS system. It connects data to people and people to data, and provides all sorts of high-performance image viewers, interaction, graphics, and data analysis.

Well, we will create a dedicated ProKnow DS hub, or domain, where the clinicians from Ocean Road can go to view anatomy and treatment plan atlases that have been provided as examples – examples of anatomy segmentation or treatment plan design, for example – based on Ocean Road’s most pressing interests and needs. Ocean Road can even upload patient image sets that they want to make their own learning cases but do not know where to start.

And this is where The Mayo Clinic comes in! See, they of course have expertise in anatomy, treatment planning, quality evaluation, immobilization, etc., and they’ll have access to the same ProKnow DS domain. One side, Ocean Road, will make requests and perhaps provide sample patient datasets about which they want more learning. The other side, The Mayo Clinic, provides the expertise and task-related outputs. For instance, Mayo experts may do the anatomy contouring or design a treatment plan approximating the delivery technology available at Ocean Road. They’ll also be able to share the dose evaluation metrics and objectives they might use, based on modern protocols. All of it becomes a living atlas of data to view, interact with, learn from.

It’s all right there, connected and shared, virtually and securely.2

And to add to that, from that growing library of case studies, certain exemplary datasets can be extracted and included in the “part one” and “part two” learning modules I described earlier: the practice and assessment modules.”

This is exciting, but I’d be remiss if I didn’t ask about data security and privacy, since we’re talking about things like medical images.

“Of course. This is where the work we’ve done for ProKnow DS serves us well. First of all, we have local DICOM service software we provide that can automatically de-identify patient data. It can be auto-anonymized, that is. In addition, all data that is uploaded and stored in ProKnow is encrypted both in transit and at rest. It’s fully HIPAA-compliant. And regarding access, it’s all via multi-factor authentication, and it can be governed by institutions’ existing federated staff login systems. So, yeah, we have all that covered. It’s important, no doubt!”

That’s good to hear. And, yes, this is all very exciting! Now, today you talked about the Ocean Road/Mayo pairing. What about beyond that? Do you have others in mind?

“The general framework will work for any pairing. And it doesn’t have to be just a pair of institutions, either. It can be three, four … however many want to partner up to form the community of sharing and learning.

We would love to see “trainee” and “trainer” nations seek each other out. And once they have, they can contact us to request the technology grant and become part of the Radiotherapy Without Borders initiative. I see it as a great opportunity to be useful, to let people share experiences and expertise with those who seek it.

I mean, just take a second to step back and look at this planet we live on. So many people, separated by barriers such as distance, language, culture, experience …. but we are all fellow humans, right? We’re not so different. We all yearn to live long, fruitful, healthy lives. I think the ProKnow technology breaks down some of the practical barriers and allows teaching, learning, sharing. It opens up the borders, so to speak, to cure more people with cancer. It’s really that simple.”

  1. Greater Horn Oncology Symposium, Zanzibar
  2. See Figure 1, below.

Figure 1. Schematic of connecting trainees and trainers virtually using ProKnow DS.